Useless general surgical interventions that should no longer be done

England’s National Health Service (NHS) could save €153 million [$178 million USD] per year by scrapping 71 low-value general surgery practices says a recently published paper in the British Journal of Surgery.

The authors, from Imperial College London, extensively reviewed the literature and Choosing Wisely recommendations from a number of countries.

I agree with many of the 71 including performing a cholecystectomy during the first admission for a patient with symptomatic gallstones instead of waiting for another admission (saving more than €54 million) and not repairing minimally symptomatic inguinal hernias, which they estimate would save over €32 million.

The Telegraph reported, “The team also discovered that robotic surgery has ‘little or no advantage’ when compared with traditional keyhole operations and said it must be ‘considered a candidate for disinvestment.’” This probably wouldn’t fly here in the US, because—like guns—too many robots are already in the hands of users.

Some low-cost but high-frequency interventions I agree should be dumped include use of mechanical bowel preparation before surgery, single-dose antibiotics for hernia surgery, and not using a drain after elective laparoscopic cholecystectomy which very few surgeons in the US do.

I was happy to see that they did not endorse the use of antibiotics instead of surgery for treating appendicitis.

But I was not happy with some of their other suggestions.

Their recommendation to save €4.3 million by eliminating CT scans for the diagnosis of appendicitis saving is misguided. They claim the percentage of negative appendectomies after CT diagnosis is similar to that seen with clinical judgment or ultrasound, but they apparently overlooked a study from the Netherlands which found quite the opposite.

It compared a sample of appendectomy patients from both countries. Only 32.8% of UK patients had preoperative imaging vs. 99.5% of patients in the Netherlands, and the rate of removing a normal appendix was 20.6% in the UK and 3.2% in the Netherlands. The latter figure is what most recently published studies of CT scanning for diagnosing appendicitis have found.

Ultrasound may not be available in all hospitals 24 hours per day, and its accuracy depends on the skill of the operator. Ultrasound is accurate when an inflamed appendix is found. An ultrasound that does not identify the appendix must be followed with another imaging study—usually a CT scan—which adds to the cost. As radiologist Saurabh Jha and I discussed in a 2016 blog post, the fear of radiation-induced cancer from CT scans may be overstated.

The Imperial College authors also recommended doing away with the use of facemasks in the operating room which would save a mere €173,000 per year. Citing a 2014 Cochrane review, they said, “There is a lack of substantial evidence to support claims that facemasks protect either patient or surgeon from infectious contamination.”

That review involved only three studies of questionable quality because of faulty randomization, bias, short or unknown duration of follow-up, and lack of criteria for defining surgical site infections.

The Cochrane authors concluded “From the limited results it is unclear whether the wearing of surgical face masks by members of the surgical team has any impact on surgical wound infection rates for patients undergoing clean surgery.”

No evidence exists that wearing a facemask protects the OR staff, but I was always glad I wore one especially when a resident [of course] cut a vessel and blood squirted in my face.

CORRECTION on 11/13/17: At the suggestion of radiology fellow @JosephMullineux, the first sentence of the last paragraph about ultrasound was amended by eliminating a phrase that implied a normal ultrasound was not useful in ruling out appendicitis.
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